Doc #5

SHS WORK IMMERSION

LIABILITY WAIVER

I am fully aware of the duties and responsibilities I will undertake through the Work Immersion
Program with cooperating industry through the request of St. Mary’s College of Tagum, Inc.:

I recognize the authority of my cooperating industry which I may be placed and submit myself to all
the rules and regulations that may be imposed upon myself the following duties.

I renounce and waive any claim against the cooperating industry and the ST. MARY’S COLLEGE OF
TAGUM, INC. for any injury that I may sustain/loss that I suffer, personal/financial in the performance
of my duties / function.

Name of Student: __________________________________

Signature: __________________________________

Date: __________________________________

PARENTAL/GUARDIAN’S CONSENT

I, ____________________________________________________, the minor’s parent and/or legal guardian, allow

my son/daughter to undergo work immersion for a minimum of 60 hours starting on
_____________________________________ until _________________________at
__________________________________________________ in partial fulfillment of the requirements for Senior
High School.

It is understood that he/she abides by the rules and regulations that may be imposed by the
Supervisor/Staff-in-Charge for his/her welfare and safety.

I fully agree to waive any responsibility on the part of ST. MARY’S COLLEGE OF TAGUM, INC., in case of
any untoward incident that may happen to my son/daughter during the duration of the WORK
IMMERSION.

Name of Parent/Legal Guardian: ____________________________________

Signature: ____________________________________
Date: ____________________________________